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Drugs preferably avoided by Brugada syndrome patients

The following drugs have been associated with the typical (type-1) Brugada syndrome ECG. However, there is (yet) no substantial evidence that these drugs can, in addition to the ECG phenotype, also cause malignant arrhythmias. Furthermore, we also listed drugs for which there is only experimental evidence (in-vivo or in-vitro) that suggests a possible deleterious effect in Brugada syndrome. However, as mentioned earlier, this deleterious effect has not been documented clearly and some patients may benefit from these drugs for other reasons. Nevertheless, it should be considered to advise patients with Brugada syndrome to avoid these drugs or to use these drugs only after extensive consideration and/or in controlled conditions.

Notes about the lists:

On this list we summarized those drugs for which there is a possible association noted in the literature between the drug and the Brugada syndrome.

Drugs are listed with up to 3 common brand names. There may be over 100 different brand names for different drugs, an effort to list those we know of you can find here. It is also important to look at the active drugs in medicines that contain a combination of drugs.

Lists contain links to DrugBank or PubChem (click on the drug name) and also (several) PubMed links to articles on the association between the drug and Brugada syndrome (click on the reference).

We advise our Brugada syndrome patients to give this letter to all of their health care providers.

Lists contain a classifying column ‘Recommendation’ in which the available evidence from the literature and the expert opinion of the BrugadaDrugs.org Advisory Boardis described. Please note that there are no randomized clinical studies in Brugada syndrome patients, therefore the level of evidence is mostly C (only consensus opinion of experts, case studies, or standard-of-care) and for some B (non-randomized studies).

Class I: There is evidence and/or general agreement that a given drug is potentially arrhythmic in Brugada syndrome patients.

Class IIa:There is conflicting evidence and/or divergence of opinion about the
drug, but the weight of evidence/opinion is in favor of a potentially arrhythmic effect in Brugada syndrome patients.

Class IIb: There is conflicting evidence and/or divergence of opinion about the
drug, and the potential arrhythmic effect in Brugada syndrome patients is less well established by evidence/opinion.

Class III: There is no or very little evidence and/or general agreement that a drug is potentially arrhythmic in Brugada syndrome patients

For information on the treatment of co-morbidities in Brugada syndrome patients several papers are available, e.g. Postema et al. 2013 (free PMC article).

Recommendation class: Class I: convincing evidence/opinion; Class IIa: evidence/opinion less clear; Class IIb: conflicting evidence/opinion; Class III: very little evidence.
† Disopyramide has been either suggested to be pro-arrhythmic or anti-arrhythmic in Brugada syndrome patients. The reason for these contradictory results is currently uncertain but could possibly include disparate underlying genetic defects. The Brugadadrugs.org Advisory Board advices caution and rigorous monitoring when using this drug to be able to react promptly to possible untoward effects.
* Lidocaine use for local anesthesia (e.g. by dentists) does seem to be safe when combined with adrenaline/epinephrine (e.g. xylocaine dental/epinephrine or articaïne/epinefrine (Ultracain® or Septanest®) 1:100,000) and the amount administrated is low as it results in a local effect only (Theodotou 2009). Also in a controlled setting such as during ICD (implantable cardioverter defibrillator) implantation there have been no descriptions of untoward events although the amount lidocaine administered can be substantial, still the utmost care should be taken to avoid systemic injection. When applied on the skin (e.g. for children requiring venapuncture or vaccination) it is also extremely unlikely that there will be systemic effects, and this will thus most probably also be safe to do.
# Use of propranolol, or rather betablockers in general, can be suitable when anti-bradycardia therapy is ensured by a pacemaker or implantable cardioverter defibrillator. Moreover, especially in the situation of a use-dependant conduction disease phenotype (see also Emergencies) betablockers are even first choice therapy to lower heart rate and decrease arrhythmic risk.

Recommendation class: Class I: convincing evidence/opinion; Class IIa: evidence/opinion less clear; Class IIb: conflicting evidence/opinion; Class III: very little evidence.
For more information on anesthetic management of Brugada syndrome patients; a review article has been written by Kloesel & Ackerman, when appropriate precautions are taken (general) anesthesia can be performed safely.

Disclaimer and Waiver
The information presented is intended solely for the purpose of providing general information about health related matters. We do our best to ascertain that all information on this site is correct and up-to-date. However, we cannot guarantee that it is. The information provided here is for educational and informational purposes only and designed primarily for use by qualified physicians and other medical professionals. It is not intended for any other purpose, including, but not limited to, medical or pharmaceutical advice and/or treatment, nor is it intended to substitute for the users’ relationships with their own health care/pharmaceutical providers. To that extent, by continued use of this program, the user affirms the understanding of the purpose and releases the Academic Medical Center, the BrugadaDrugs.org Advisory Board and Cardionetworks from any claims arising out of his/her use of the website.

Principal limitation
It should be clear to the users of this site that the principal limitation of the association between certain drugs, Brugada syndrome and arrhythmias, is that there are quite often only (a number of) case reports and experimental studies suggesting an effect in Brugada syndrome. Further, there may conflicting results and there may be large variability for Brugada syndrome patients in their response to certain drugs. This response may also differ in different conditions (e.g. with or without fever, drug in therapeutic range, overdosed or in combination with other drugs etc.). Clinical decision making should be based on more than the presence or absence of a (single) association in another patient.

Please cite as

Recommended

Patients and medical professionals: to stay up to date, please sign up for the update service here.Physicians: in the case of asymptomatic
patients, please submit your patients to the Quinidine vs. controls registry on www.BrugadaSyndrome.info.

Long QT syndrome

For drugs to avoid in Long QT syndrome, please go to www.QTdrugs.org (handled by CredibleMeds)

Google Translator

Please acknowledge that the Google translator will not be 100% accurate.